| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,437 |
1,434 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
387 |
253 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,771 |
1,767 |
$44K |
| D1110 |
Prophylaxis - adult |
668 |
666 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,223 |
1,223 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
215 |
138 |
$20K |
| D0274 |
Bitewings - four radiographic images |
569 |
566 |
$18K |
| D1206 |
Topical application of fluoride varnish |
226 |
225 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
136 |
136 |
$5K |
| D0330 |
Panoramic radiographic image |
57 |
57 |
$3K |
| D0272 |
Bitewings - two radiographic images |
131 |
131 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$969.69 |